A Long Journey of the Heart

Ozzie Rivero found out early Tuesday afternoon that a young patient at a community hospital in Chicago had died on life support. The patient’s heart was still beating as a machine filled his lungs with air, but he would never open his eyes again. In their grief, his family was willing to give his organs to others.

The University of Chicago Medical Center had a patient near the same age with the same blood type at the top of the list for a heart.

Ozzie Rivero had to get that heart from a dead patient to a barely living one.

Rivero is a manager of organ procurement, part of the team that coordinates the collection of hearts, lungs, kidneys, livers, and pancreases from deceased donors for transplant at the Medical Center.

The community hospital told Rivero that he could come for the heart in a few hours, when an operating room was available. Maybe 10:30 p.m. At the moment, the ER was crowded with people suffering through the summer heat wave and all the ORs were full.

Two surgeons prepared to perform heart surgery at the same time: Mark Russo, MD, would go to the community hospital with Rivero to remove the heart and Jai Raman, MD, would put the heart into his patient.

A nurse called Raman’s patient and explained that there was a possibility of getting a heart. But only a possibility. Raman’s patient came to the Medical Center, and got ready for surgery.

At 8:30 p.m., the community hospital delayed Rivero – more major trauma cases were in their operating rooms, and the procurement would have to wait until at least midnight.

At 9:30 p.m., the hospital delayed Rivero again, this time until after 1 a.m.

Raman’s patient waited, along with the nurses, anesthesiologists, physician assistants, transporters, and residents who stood ready for one of the most complex surgeries performed at the Medical Center.

At 12:30 a.m., Rivero walked out of the hospital toward a white SUV idling in a cul-de-sac on 58th Street, the air conditioning on full blast against the swampy night air. “Hey Herb,” he said to the driver as he opened the back and tossed in a duffel bag and a red cooler full of ice.

The car pulled away from the hospital as Rivero’s cellphone rang—it was Operating Room 16, where all the heart transplants happen. They wanted an update. “You can put the patient to sleep,” Rivero said.

Rivero called Raman, who had gone home in the hope of getting a little time with his family before the marathon surgery began. “They’re putting the patient under,” he said. Raman thanked him for the update and prepared to come back in to the hospital.

Many organ procurements are at night, when ORs are otherwise empty and grieving families have gone home. Rivero skips a lot of sleep in his job, and has seen many of his colleagues give up. “The turnover is high when you never get to meet the recipients or see the success stories,” he said. “We don’t meet the guy who got a new life.” The driver dropped Rivero and the surgeon Mark Russo at the community hospital’s emergency room, and waited outside.

The young man lay on a gurney in a large OR, dead from a traumatic head injury. The air conditioning was broken, and the room got hotter with each person who scrubbed in and gathered around his body. Mark Russo changed into scrubs, washed his hands in a steel sink, tied on a hat and face mask, and pushed open the double doors.

The patient had been cut open from his sternum to his lower abdomen, and surgeons from other hospitals in Chicago—Northwestern, UIC, and Loyola—prepared his kidneys, pancreas, lungs, and liver for transplantation, too.

A nurse helped Russo into a sterile blue gown that covered him to his shins, and two pairs of rubber gloves. He had to see for himself if the heart was the right size for Raman’s patient, now anesthetized on a bed at the Medical Center. There are many false starts in this business, when the heart won’t work for the transplant patient. Rivero said he comes back without a heart on 20% of his procurement trips.

He peered into the open cavity where the young man’s heart twitched as the life support machine raised and lowered his lungs. “The heart is fine,” Russo said. It was 1:30 in the morning.

Rivero called OR 16 at the Medical Center and passed along the message. “It’s a good heart; you can make the incision.” With that knowledge, Raman would open up his patient’s chest. “We’ll cross clamp in 30 minutes,” Rivero told Raman.

Wait, Raman said. He had to take out not just a heart, but a ventricular assist device, or VAD, from his patient’s chest cavity, too. That would take much longer than an hour.

When the surgeon cross clamps, or cuts off the blood to the donor heart, the clock starts ticking. A heart will live for five hours outside of the body. Ozzie can’t bring the donor heart to the hospital too early, or it will die in the cooler before the surgeon can implant it. If he brings it too late, the patient could go too long without any heart at all. Organ procurement is one corner in the complex and mistake-prone industry of delivering medicine where the timing has to be perfect.

“We need more time,” Rivero announced to the more than a dozen people in the OR. “We have to dig out a VAD.”

Rivero called OR 16 a few more times over the next hour. People walked in and out of the double doors, calling their own hospitals with guesses about when their respective organs would arrive. The procurement world is small, and people asked each other about former colleagues and reminisced about heat waves in previous summers. A guy in scrubs sat on a stool near Rivero and played Scrabble on his iPhone. Unlike operations on a living patient, this one was loud and relaxed.

At 2:30 a.m., Rivero emptied ice into a small bucket on a table near the foot of the bed. Russo started cutting. He needed to cut through every vein and artery in the heart, and to preserve enough length to graft each one into the recipient’s chest. But the hospital taking the lungs wanted long veins and arteries, too. Russo quickly negotiated with the other surgeons about where he would cut.

At 2:53, the life support machine beeped loud and fast, and the lines on the screen went flat. Russo had cut through the aorta. The hum of the OR cranked up to a roar. Bags of fluid flushed through all the organs that were going into new bodies that morning, to keep the cells from dying without blood and oxygen.

“We have cross clamped, at 2:53,” Rivero said to the nurse in OR 16. Next to Rivero, a coordinator from Gift of Hope, the group that arranges organ allocation in Illinois and northwest Indiana, wrote “CC 0253” on his scrubs.

Russo lifted the heart out of the patient’s chest. It fit easily into one hand, but he carried it in two. He brought it to the small bucket with ice, flushed the heart with more cardioplegic solution, and set the heart in a clear jar. Rivero screwed on the cap, put the jar in the red cooler, and rushed out of the room.

Rivero and Russo walked briskly through the labyrinth of the hospital, and got back to the waiting SUV at 3:22 a.m. The driver turned on a siren and flashing lights, and started toward the University of Chicago. Cars slowed down and pulled off the road as the SUV rolled through red lights and stop signs. Rivero called OR 16 again. “We’ll be there in 10 minutes,” he said. A heat storm blew in and lit up the Chicago skyline with lightning.

At 4:00 a.m., the SUV arrived at the cul-de-sac on 58th Street.

Rivero rolled the red cooler into OR 16. The operating room was silent and cool, with just the beep of the anesthesia and cardiopulmonary bypass machines. Jai Raman didn’t look up. He was still cutting the various lines and tubes around his patient’s heart and VAD. This extraction was particularly complicated.

Just before 5 a.m., Raman reached into his patient’s chest and pulled out a distended and enlarged heart. Colorful lines from the VAD, which had kept the patient alive for months, poked out of the heart at odd angles. The heart was a deep maroon and covered in dark adhesions, little scars where the body had fought against it. The physician’s assistant opened the red cooler. Near the gaping hole in the patient’s chest, he laid what looked like a perfect new heart. Raman and his team in surgery still had hours to go before they could send blood through it.

Rivero wouldn’t be around to see the patient wake up from anesthesia that afternoon. He’d be filling out paperwork from this procurement, and getting ready for the next one.